| NPI | 1568023612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NY F344484-1) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 720528-1) |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2021-03-12 |