| NPI | 1629342308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3008001) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209008816) |
| Enumeration Date | 2012-02-28 |
| Last Update Date | 2025-03-17 |