| NPI | 1639903677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 359932) |
| Additional Taxonomies | 174400000X Specialist (Licence: NY 880864) |
| Enumeration Date | 2024-08-30 |
| Last Update Date | 2026-08-11 |