NPI | 1669003273 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11035475) |
Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209026805) |
363LF0000X Nurse Practitioner, Family (Licence: MI 4704288263) | |
Enumeration Date | 2020-02-01 |
Last Update Date | 2025-05-28 |