| NPI | 1255616934 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: OH COA12623NP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704241503) |
| Enumeration Date | 2011-10-13 |
| Last Update Date | 2012-05-03 |