| NPI | 1689551483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704363009) |
| Additional Taxonomies | 163WP0200X Registered Nurse, Pediatrics (Licence: MI 4704363009) |
| Enumeration Date | 2025-08-21 |
| Last Update Date | 2025-11-21 |