| NPI | 1104372606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NJ 26NJ00693200) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NJ 26NR16306700) |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2020-10-22 |