| NPI | 1003247826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704263271) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: MI 4704263271) |
| Enumeration Date | 2013-12-04 |
| Last Update Date | 2018-12-26 |