| NPI | 1205529567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 311317) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 736924) |
| Enumeration Date | 2023-06-01 |
| Last Update Date | 2024-05-07 |