| NPI | 1194510701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704329271) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID 6041762) |
| Enumeration Date | 2025-04-14 |
| Last Update Date | 2025-06-10 |