| NPI | 1104384106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MI 4704288276) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704288276) |
| Enumeration Date | 2019-03-08 |
| Last Update Date | 2023-08-02 |