| NPI | 1366711103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 339074) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 617047) |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2025-12-05 |