| NPI | 1780125963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: NY 654383) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY F339919-1) |
| Enumeration Date | 2017-03-20 |
| Last Update Date | 2017-03-20 |