| NPI | 1386750404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 4024180) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209004993) |
| Enumeration Date | 2006-08-22 |
| Last Update Date | 2024-07-02 |