| NPI | 1932775889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704333424) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704333424) |
| Enumeration Date | 2021-06-01 |
| Last Update Date | 2025-01-23 |