| NPI | 1265424527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704141572) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 47-04-141572) |
| Enumeration Date | 2005-08-22 |
| Last Update Date | 2023-08-15 |