| NPI | 1104234053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209-011828) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041-384463) |
| Enumeration Date | 2014-07-23 |
| Last Update Date | 2020-02-05 |