| NPI | 1639270473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704188756) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704188756) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2021-03-31 |