| NPI | 1629451596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704341244) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA AP08422) |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2024-07-11 |