| NPI | 1912514654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: IL 277002815) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IL 070023590) |
| 163W00000X Registered Nurse (Licence: IL 041338230) | |
| 363L00000X Nurse Practitioner (Licence: IL 209021853) | |
| Enumeration Date | 2020-09-27 |
| Last Update Date | 2023-12-13 |