| NPI | 1508466079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4704326807) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704326807) |
| Enumeration Date | 2020-10-26 |
| Last Update Date | 2023-06-22 |