| NPI | 1710366489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 16339) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95018633) |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2026-01-26 |