| NPI | 1417943903 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IA A080476)  | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209002893)  | 
| Enumeration Date | 2005-09-21 | 
| Last Update Date | 2023-03-07 |