| NPI | 1083064117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: MI 47404217162) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: MI 5502001615) |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2024-09-13 |