| NPI | 1912347600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2020028154) |
| Additional Taxonomies | 363LA2100X Nurse Practitioner, Acute Care (Licence: IL 209011793) |
| Enumeration Date | 2013-06-27 |
| Last Update Date | 2021-06-17 |