| NPI | 1376913822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704292386) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MI 4704292386) |
| Enumeration Date | 2015-09-28 |
| Last Update Date | 2025-04-10 |