| NPI | 1255709374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11012853) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY F340015-1) |
| Enumeration Date | 2015-09-05 |
| Last Update Date | 2021-08-05 |