| NPI | 1528467313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704268598) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704268598) |
| Enumeration Date | 2014-08-18 |
| Last Update Date | 2014-08-18 |