| NPI | 1184198590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2299446) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NH 071461-23) |
| Enumeration Date | 2019-01-18 |
| Last Update Date | 2019-12-12 |