| NPI | 1922417807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2297770) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: CT 5790) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: MA RN2297770) | |
| Enumeration Date | 2014-08-05 |
| Last Update Date | 2015-02-11 |