| NPI | 1205258258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: NY F311097-01) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 546269-1) |
| Enumeration Date | 2014-01-10 |
| Last Update Date | 2023-07-19 |