| NPI | 1376262550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704345816) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MI 4704345816) |
| Enumeration Date | 2022-08-23 |
| Last Update Date | 2022-11-16 |