| NPI | 1083008924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 8806) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 671723) |
| 363LG0600X Nurse Practitioner, Gerontology (Licence: NY F307678) | |
| Enumeration Date | 2015-03-27 |
| Last Update Date | 2022-05-10 |