| NPI | 1104237130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 277-000310) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209-011657) |
| 163W00000X Registered Nurse (Licence: IL 041.368559) | |
| Enumeration Date | 2014-05-13 |
| Last Update Date | 2021-11-26 |