| NPI | 1790178333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 306282) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 600937) |
| Enumeration Date | 2015-03-06 |
| Last Update Date | 2015-03-06 |