| NPI | 1104130947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 343149) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 632777) |
| Enumeration Date | 2010-08-04 |
| Last Update Date | 2023-09-27 |