| NPI | 1376080648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2287152) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2287152) |
| Enumeration Date | 2017-01-25 |
| Last Update Date | 2018-03-17 |