| NPI | 1073965083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 21363) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MI 4704366480) |
| 363LF0000X Nurse Practitioner, Family (Licence: TN 21363) | |
| Enumeration Date | 2016-07-01 |
| Last Update Date | 2021-02-25 |