| NPI | 1033579560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 346800) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 711721) |
| Enumeration Date | 2016-02-25 |
| Last Update Date | 2020-10-28 |