| NPI | 1063883759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 350680) |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency (Licence: NY 693204-1) |
| Enumeration Date | 2015-10-07 |
| Last Update Date | 2022-12-12 |