| NPI | 1326653502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704286495) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704286495) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704286495) | |
| Enumeration Date | 2020-09-14 |
| Last Update Date | 2023-12-13 |