| NPI | 1053789784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA NP95004934) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209.013162) |
| Enumeration Date | 2015-09-11 |
| Last Update Date | 2019-12-04 |