| NPI | 1124894050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: MI 47044413636) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: MO 2024000132) |
| Enumeration Date | 2023-12-01 |
| Last Update Date | 2024-07-18 |