| NPI | 1003066143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704234332) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: MI 4704234332) |
| Enumeration Date | 2008-09-25 |
| Last Update Date | 2025-07-24 |