| NPI | 1164258430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704365484) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704365484) |
| Enumeration Date | 2024-09-12 |
| Last Update Date | 2024-11-11 |