| NPI | 1154711711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.0029419) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MA 2291907) |
| Enumeration Date | 2015-02-03 |
| Last Update Date | 2025-05-13 |