| NPI | 1124526652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209-017304) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041-390506) |
| Enumeration Date | 2018-01-30 |
| Last Update Date | 2021-03-08 |