| NPI | 1740229053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704321379) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NM R54642) |
| 363L00000X Nurse Practitioner (Licence: OR 2005500339NP/40NP) | |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2016-10-26 |