| NPI | 1003699307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209.028553) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.426288) |
| Enumeration Date | 2023-08-18 |
| Last Update Date | 2023-10-27 |