| NPI | 1629757307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704324445) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704324445NSA230IK) |
| Enumeration Date | 2023-07-12 |
| Last Update Date | 2023-07-12 |