| NPI | 1205411071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11028008) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NJ NJDCATEMP-038698) |
| Enumeration Date | 2021-03-13 |
| Last Update Date | 2023-08-15 |