| NPI | 1568577872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 304072) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY F304072 / 494154) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2017-12-05 |