| NPI | 1083231963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704330613) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704330613) |
| Enumeration Date | 2020-06-26 |
| Last Update Date | 2022-10-07 |