| NPI | 1245856657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2023047204) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209023840) |
| 363LF0000X Nurse Practitioner, Family (Licence: IL 209023840) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-22 |
| Last Update Date | 2024-04-26 |