| NPI | 1205236973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704236050) |
| Additional Taxonomies | 275N00000X Medicare Defined Swing Bed Unit (Licence: MI 4704236050) |
| Enumeration Date | 2014-08-29 |
| Last Update Date | 2020-01-08 |