| NPI | 1871484204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY 383812) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MI 4704377472) |
| Enumeration Date | 2025-07-14 |
| Last Update Date | 2026-03-17 |