| NPI | 1790329746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY F351735-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 353-P.A.) |
| 363LF0000X Nurse Practitioner, Family (Licence: NJ 26NJ14950400) | |
| Enumeration Date | 2019-11-02 |
| Last Update Date | 2024-09-10 |