| NPI | 1629435102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.013755) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 19531) |
| Enumeration Date | 2016-01-28 |
| Last Update Date | 2022-04-20 |