| NPI | 1215566435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 17818-33) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 277003776) |
| 163W00000X Registered Nurse (Licence: IL 041409625) | |
| Enumeration Date | 2020-04-08 |
| Last Update Date | 2026-03-30 |