| NPI | 1477060598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP018379) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 358222) |
| Enumeration Date | 2018-01-10 |
| Last Update Date | 2025-11-12 |