| NPI | 1861383820 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 357491) | 
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WA RN61576608) | 
| 163W00000X Registered Nurse (Licence: NY 962375) | |
| 163W00000X Registered Nurse (Licence: CT 211405) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2025-07-09 | 
| Last Update Date | 2025-09-17 |