| NPI | 1174976500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 307611) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 607561) |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2016-07-20 |