| NPI | 1679351258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 16672-33) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209.028122) |
| Enumeration Date | 2023-09-15 |
| Last Update Date | 2025-10-18 |