| NPI | 1679825624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: NY 337507) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 337507) |
| 363LF0000X Nurse Practitioner, Family (Licence: NY 337505) | |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2023-11-01 |