| NPI | 1629718879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209.025276) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.471722) |
| Enumeration Date | 2022-03-29 |
| Last Update Date | 2022-06-05 |