| NPI | 1154906709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704251873) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 0000000000) |
| 163W00000X Registered Nurse (Licence: MI 4704251873) | |
| Enumeration Date | 2021-03-16 |
| Last Update Date | 2024-02-19 |