| NPI | 1104343235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 277003302) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IN 71013534A) |
| 363L00000X Nurse Practitioner (Licence: KY 3011300) | |
| 363LF0000X Nurse Practitioner, Family (Licence: OH APRN.CNP.020842) | |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2024-08-14 |