| NPI | 1528500774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704301848) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: MI 4704301848) |
| Enumeration Date | 2016-11-04 |
| Last Update Date | 2023-04-06 |