| NPI | 1265041123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CT 9894) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 122804) |
| Enumeration Date | 2020-07-27 |
| Last Update Date | 2025-04-11 |