| NPI | 1356974760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024190321) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 345537) |
| Enumeration Date | 2020-02-14 |
| Last Update Date | 2024-06-28 |