| NPI | 1912359563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 340763) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 658301) |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2022-02-26 |