| NPI | 1487170122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704271979) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704271979) |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2024-11-26 |