| NPI | 1861170631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 358500) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 856353) |
| Enumeration Date | 2023-07-10 |
| Last Update Date | 2026-05-13 |