| NPI | 1700577442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704366941) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN296223) |
| Enumeration Date | 2023-05-15 |
| Last Update Date | 2025-11-10 |