| NPI | 1508423393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704300946) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704300964) |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2025-12-12 |