| NPI | 1134606858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2018004234) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209017813) |
| Enumeration Date | 2018-07-25 |
| Last Update Date | 2022-01-05 |