| NPI | 1962850719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: IL 209014144) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: IL 209014144) |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2016-06-01 |