| NPI | 1144871773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11006946) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704319616) |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2020-08-10 |