| NPI | 1649564253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA 262017) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: MA 262017) |
| Enumeration Date | 2011-06-01 |
| Last Update Date | 2011-06-01 |