| NPI | 1487291332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704287652) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704287652) |
| Enumeration Date | 2019-12-10 |
| Last Update Date | 2020-02-19 |