| NPI | 1790595676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 358143) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 685966) |
| Enumeration Date | 2025-01-13 |
| Last Update Date | 2025-10-31 |