| NPI | 1790311454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11006635) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704420118) |
| Enumeration Date | 2020-03-13 |
| Last Update Date | 2024-10-22 |