| NPI | 1609149293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NJ 26NJ00480700) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA TAP002743) |
| Enumeration Date | 2012-02-14 |
| Last Update Date | 2016-05-04 |