| NPI | 1063455004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NJ 26NJ00066600) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA SP009079) |
| 363LF0000X Nurse Practitioner, Family (Licence: MD R142342) | |
| 363LF0000X Nurse Practitioner, Family (Licence: TX 714376) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2021-12-12 |