| NPI | 1679019400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209015670) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2017001791) |
| 163W00000X Registered Nurse (Licence: MO 131063) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MO 2017001791) | |
| Enumeration Date | 2017-01-18 |
| Last Update Date | 2017-04-05 |