| NPI | 1104593060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 11369-33) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209024153) |
| 363LF0000X Nurse Practitioner, Family (Licence: WI 11369-33) | |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2023-12-04 |