| NPI | 1639688419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 345484-1) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 719617-1) |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2020-05-29 |