| NPI | 1952053258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ 305068) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704369610) |
| Enumeration Date | 2022-01-19 |
| Last Update Date | 2024-11-02 |