| NPI | 1114271418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: IL 209009884) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.009884) |
| Enumeration Date | 2012-11-08 |
| Last Update Date | 2015-08-19 |