| NPI | 1639879703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704319078) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704319078NSA2304W) |
| 163W00000X Registered Nurse (Licence: MI 4704319078) | |
| Enumeration Date | 2023-03-07 |
| Last Update Date | 2025-03-04 |