| NPI | 1619438744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209.018590) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: WA AP61018849) |
| Enumeration Date | 2019-03-29 |
| Last Update Date | 2021-05-13 |