| NPI | 1326030727 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LX0001X Nurse Practitioner, Obstetrics & Gynecology (Licence: MI 4704146078) | 
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MI 4704146078) | 
| Enumeration Date | 2005-08-22 | 
| Last Update Date | 2007-07-15 |