| NPI | 1568057750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704277638) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: MI 4704277638) |
| Enumeration Date | 2021-03-09 |
| Last Update Date | 2023-06-27 |