| NPI | 1548646755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.017450) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.405343) |
| Enumeration Date | 2015-08-11 |
| Last Update Date | 2026-07-17 |