| NPI | 1457762627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ND R39904) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704271458) |
| 363LF0000X Nurse Practitioner, Family (Licence: IA A148655) | |
| 363LF0000X Nurse Practitioner, Family (Licence: ND R39904) | |
| Enumeration Date | 2014-05-09 |
| Last Update Date | 2019-11-25 |