| NPI | 1194506717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MA RN2290873) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MA CNP2290873) |
| 363LF0000X Nurse Practitioner, Family (Licence: FL 11026013) | |
| Enumeration Date | 2023-10-10 |
| Last Update Date | 2025-01-14 |