| NPI | 1154763639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 343321) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 669001) |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2021-08-18 |