| NPI | 1457462160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MO 066852) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 041-268951) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2017-04-11 |