| NPI | 1619406873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP018240) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY F342441-1) |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2021-03-08 |