| NPI | 1790418465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209025232) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.025232) |
| Enumeration Date | 2022-07-08 |
| Last Update Date | 2025-09-23 |