| NPI | 1629524194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704278542) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704278542) |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2022-10-24 |