| NPI | 1720611247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5015060) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY F344909) |
| 163W00000X Registered Nurse (Licence: NY 711527) | |
| Enumeration Date | 2020-02-13 |
| Last Update Date | 2024-02-06 |