| NPI | 1922747054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704348360) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 47043483) |
| Enumeration Date | 2022-05-27 |
| Last Update Date | 2023-05-10 |