| NPI | 1114358033 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 201600270NP-PP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209-011006) |
| Enumeration Date | 2013-12-02 |
| Last Update Date | 2021-02-15 |