| NPI | 1083168520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 359476) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 749721) |
| Enumeration Date | 2016-08-13 |
| Last Update Date | 2026-04-24 |