| NPI | 1548802713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: MI 4704303838) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner Adult Health (Licence: MI 4704303838) |
| 363LG0600X Nurse Practitioner Gerontology (Licence: MI 4704303838) | |
| Enumeration Date | 2019-10-09 |
| Last Update Date | 2019-10-09 |