| NPI | 1598015570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704320486) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TN 184307) |
| 163W00000X Registered Nurse (Licence: WY 3896) | |
| 163W00000X Registered Nurse (Licence: WY 31294.1210) | |
| 363L00000X Nurse Practitioner (Licence: WY 31294.1210) | |
| Enumeration Date | 2012-09-17 |
| Last Update Date | 2016-08-17 |