| NPI | 1104378264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MI 4704249478) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: MI 4704249478) |
| Enumeration Date | 2016-10-25 |
| Last Update Date | 2016-10-25 |