| NPI | 1124514534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11003681) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11003681) |
| 363LF0000X Nurse Practitioner, Family (Licence: NJ 26NJ00817100) | |
| Enumeration Date | 2018-07-09 |
| Last Update Date | 2026-06-24 |