| NPI | 1568181329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 277004400) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 32009) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: IL 277004400) | |
| Enumeration Date | 2022-08-25 |
| Last Update Date | 2025-12-15 |