| NPI | 1881247260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704396348) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY 382991) |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2023-10-19 |