| NPI | 1912596735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MA RN2292412) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2292412) |
| Enumeration Date | 2021-01-15 |
| Last Update Date | 2026-06-18 |