| NPI | 1073078457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 12712) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MA RN2300344) |
| Enumeration Date | 2019-02-10 |
| Last Update Date | 2024-05-01 |