| NPI | 1972605715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704210566) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704210566) |
| Enumeration Date | 2006-09-02 |
| Last Update Date | 2025-05-14 |