| NPI | 1760149660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 343781) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 656739) |
| Enumeration Date | 2021-11-26 |
| Last Update Date | 2021-11-26 |