| NPI | 1992122683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: MA RN2291820) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2291820) |
| Enumeration Date | 2014-03-19 |
| Last Update Date | 2015-07-29 |