| NPI | 1811339146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A136582) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 4704258752) |
| Enumeration Date | 2013-07-29 |
| Last Update Date | 2020-12-17 |