| NPI | 1306551486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 16677-33) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IL 209026572) |
| Enumeration Date | 2023-01-23 |
| Last Update Date | 2025-08-17 |