| NPI | 1982339388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MI 4704328662) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704328662) |
| Enumeration Date | 2022-07-19 |
| Last Update Date | 2025-06-19 |