| NPI | 1639682990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 308177) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 308177) |
| Enumeration Date | 2017-11-09 |
| Last Update Date | 2022-04-04 |