| NPI | 1578042362 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CT 7723) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 343373) | 
| Enumeration Date | 2018-08-13 | 
| Last Update Date | 2025-06-03 |