| NPI | 1770166944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2323055) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2323055) |
| 363LF0000X Nurse Practitioner, Family (Licence: MA F09201476) | |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2021-10-22 |