| NPI | 1265700090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2100X Nurse Practitioner Acute Care (Licence: IN 71003819A) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704338962) |
| Enumeration Date | 2011-12-07 |
| Last Update Date | 2021-03-30 |