| NPI | 1972930733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: TN 17935) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MA RN2281187) |
| Enumeration Date | 2013-10-10 |
| Last Update Date | 2013-10-10 |