| NPI | 1578921532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 9252) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209013762) |
| Enumeration Date | 2016-02-05 |
| Last Update Date | 2024-08-29 |