| NPI | 1710457718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704257968) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: HI 2562) |
| Enumeration Date | 2018-12-03 |
| Last Update Date | 2020-06-10 |