| NPI | 1952564551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: IL 209-000798) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209-000798) |
| 363LA2100X Nurse Practitioner Acute Care (Licence: IL 209-000798) | |
| 363LC1500X Nurse Practitioner Community Health (Licence: IL 209-000798) | |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2008-07-03 |