| NPI | 1972065423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.019193) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041458306) |
| Enumeration Date | 2019-04-03 |
| Last Update Date | 2019-11-07 |