| NPI | 1629640446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2311699) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2311699) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2022-01-14 |