| NPI | 1639424716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MO 2020028106) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: IN 08002660A) |
| 363LF0000X Nurse Practitioner Family (Licence: IL 209021715) | |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2020-10-28 |