| NPI | 1811727548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704420004) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MI 4704420004) |
| 363LF0000X Nurse Practitioner, Family (Licence: PA SP030312) | |
| Enumeration Date | 2024-08-06 |
| Last Update Date | 2024-12-18 |