| NPI | 1053668707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 041.338786) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA AP60659217) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2026-02-18 |