| NPI | 1154916773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 202107301NP-PP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209022602) |
| Enumeration Date | 2021-03-05 |
| Last Update Date | 2022-12-09 |