| NPI | 1679620082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2023010527) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209027238) |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2026-02-06 |