| NPI | 1801112420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209008088) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: AK 1441) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 95089847) | |
| Enumeration Date | 2010-04-08 |
| Last Update Date | 2021-06-09 |