NPI | 1245636091 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MI 4704263525) |
Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704263525) |
Enumeration Date | 2014-11-06 |
Last Update Date | 2025-05-29 |