| NPI | 1376085191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704266089) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704266089) |
| Enumeration Date | 2016-11-10 |
| Last Update Date | 2023-05-23 |