| NPI | 1679461818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 312441) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 795387) |
| Enumeration Date | 2025-06-26 |
| Last Update Date | 2025-08-22 |