| NPI | 1194207902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP021422) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 343551) |
| Enumeration Date | 2018-08-29 |
| Last Update Date | 2021-11-22 |