| NPI | 1013164110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 545136) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 545136-1) |
| Enumeration Date | 2008-08-20 |
| Last Update Date | 2021-10-11 |