| NPI | 1124380308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY F405095-1) |
| Additional Taxonomies | 174400000X Specialist (Licence: NY 891809) |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2025-10-21 |