| NPI | 1508417031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 79519) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704307161) |
| 363LF0000X Nurse Practitioner, Family (Licence: MI 4704307161) | |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2024-08-05 |