| NPI | 1629749718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NY 348511) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 348511) |
| Enumeration Date | 2021-09-28 |
| Last Update Date | 2023-07-17 |