| NPI | 1073077715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704223808) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.024070) |
| 363LF0000X Nurse Practitioner, Family (Licence: OH RN251795) | |
| Enumeration Date | 2019-01-28 |
| Last Update Date | 2023-11-03 |