| NPI | 1235504945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704243592) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704243592) |
| Enumeration Date | 2015-12-07 |
| Last Update Date | 2024-07-17 |