| NPI | 1275931123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MI 4704257068) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704257068) |
| Enumeration Date | 2014-12-09 |
| Last Update Date | 2021-02-08 |