| NPI | 1548711971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.014709) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.407978) |
| Enumeration Date | 2016-10-20 |
| Last Update Date | 2025-12-04 |