| NPI | 1154939064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NJ 26NJ01046900) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 346148) |
| Enumeration Date | 2020-07-16 |
| Last Update Date | 2022-01-09 |