| NPI | 1063954485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA 253207) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA 153207) |
| Enumeration Date | 2016-11-16 |
| Last Update Date | 2017-03-13 |