| NPI | 1235868506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704301517) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.0032384) |
| Enumeration Date | 2022-06-09 |
| Last Update Date | 2026-01-23 |