| NPI | 1790660264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209.33402) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.364416) |
| Enumeration Date | 2025-08-06 |
| Last Update Date | 2025-09-30 |