| NPI | 1710601570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MI 4704246900) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4704246900) |
| Enumeration Date | 2022-09-26 |
| Last Update Date | 2025-08-12 |