| NPI | 1659975969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CT 9402) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MD R208334) |
| 163W00000X Registered Nurse (Licence: CT 114524) | |
| 363L00000X Nurse Practitioner (Licence: CT 9402) | |
| Enumeration Date | 2020-11-27 |
| Last Update Date | 2021-08-27 |