| NPI | 1760086383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704294652) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 19088110315) |
| Enumeration Date | 2020-11-24 |
| Last Update Date | 2021-02-05 |