| NPI | 1972589919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209004084) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085-000253) |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2021-12-20 |