| NPI | 1811660533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: IL 209023162) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: IN 28294630A) |
| Enumeration Date | 2021-07-28 |
| Last Update Date | 2025-07-16 |