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 |