| NPI | 1356093553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704341497) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704341497) |
| 363LF0000X Nurse Practitioner, Family (Licence: MI F09220623) | |
| Enumeration Date | 2022-01-19 |
| Last Update Date | 2024-06-05 |