| NPI | 1720492507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.011406) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.248851) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2024-05-09 |