| NPI | 1720859614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 12.013236) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 134553) |
| Enumeration Date | 2024-01-10 |
| Last Update Date | 2024-06-18 |