| NPI | 1164516761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2017031313) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 252969) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2024-02-12 |