| NPI | 1558369363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NJ 26NN10322000) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NJ 26NN10322000) |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2008-08-04 |