| NPI | 1912582339 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: IL 209023030) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209.023030) |
| Enumeration Date | 2021-03-17 |
| Last Update Date | 2023-03-07 |