| NPI | 1639789746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CT 12.009228) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 89958) |
| Enumeration Date | 2020-08-04 |
| Last Update Date | 2020-10-01 |