| NPI | 1215811948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 18019) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 10.188585) |
| Enumeration Date | 2025-08-05 |
| Last Update Date | 2026-09-13 |