| NPI | 1093791469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 483389) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CT 003246) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2013-03-20 |