| NPI | 1962453043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NH 056047-23) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MA 236916) |
| Enumeration Date | 2006-05-13 |
| Last Update Date | 2015-03-03 |