| NPI | 1982160990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2018040228) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209020503) |
| Enumeration Date | 2019-02-14 |
| Last Update Date | 2021-12-06 |