| 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 |