| NPI | 1639064710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.032907) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN277604) |
| 163W00000X Registered Nurse (Licence: IL 041.589724) | |
| Enumeration Date | 2025-06-10 |
| Last Update Date | 2025-08-08 |