| NPI | 1104815836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 341666) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VT 101-0136760) |
| Enumeration Date | 2005-10-15 |
| Last Update Date | 2023-12-28 |