| NPI | 1962041897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2257992) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MA 2019074184) |
| Enumeration Date | 2019-12-23 |
| Last Update Date | 2021-06-28 |