| NPI | 1174048219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704288308) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704288308) |
| Enumeration Date | 2017-08-10 |
| Last Update Date | 2019-09-11 |