| NPI | 1063839504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209011397) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2014022531) |
| Enumeration Date | 2014-03-21 |
| Last Update Date | 2020-05-28 |