| NPI | 1861867889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: MI 4704274231) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: MI 4704274231) |
| 261QP2300X Clinic/Center, Primary Care (Licence: MI 4704274231) | |
| Enumeration Date | 2015-12-02 |
| Last Update Date | 2026-01-30 |