| NPI | 1184101586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 8641) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209029946) |
| 363LF0000X Nurse Practitioner, Family (Licence: WI 8641-33) | |
| Enumeration Date | 2018-07-27 |
| Last Update Date | 2024-09-27 |