| NPI | 1245851021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA AG06200203) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2335047) |
| Enumeration Date | 2020-05-03 |
| Last Update Date | 2021-06-01 |