| NPI | 1962779702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 340071) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 624288) |
| Enumeration Date | 2011-11-22 |
| Last Update Date | 2015-10-13 |