| NPI | 1982213997 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 9280) | 
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95029148) | 
| 363L00000X Nurse Practitioner (Licence: MA RN2391405) | |
| 363L00000X Nurse Practitioner (Licence: NY 351723) | |
| Enumeration Date | 2020-07-26 | 
| Last Update Date | 2025-10-25 |