| NPI | 1174282099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95022391) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209.023999) |
| Enumeration Date | 2021-12-08 |
| Last Update Date | 2023-08-31 |