| NPI | 1104407329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: NY 279184) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2025-06-30 |