| NPI | 1083296461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 77436) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704303974) |
| Enumeration Date | 2021-04-25 |
| Last Update Date | 2023-12-11 |