| NPI | 1629915681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY 383940) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 865061) |
| Enumeration Date | 2026-04-29 |
| Last Update Date | 2026-07-13 |