| NPI | 1336425560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 085004797) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004653) |
| Enumeration Date | 2011-11-02 |
| Last Update Date | 2024-05-07 |