| NPI | 1770215428 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704311330) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IN 28221256A) |
| Enumeration Date | 2022-06-29 |
| Last Update Date | 2023-08-15 |