| NPI | 1417300112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: CT 9385) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 307846) |
| Enumeration Date | 2016-07-18 |
| Last Update Date | 2025-08-27 |