| NPI | 1730966102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704316057) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704316057) |
| Enumeration Date | 2023-09-11 |
| Last Update Date | 2024-02-22 |