| NPI | 1053904805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 2021102560) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704350108) |
| Enumeration Date | 2021-02-12 |
| Last Update Date | 2023-01-09 |