| NPI | 1013576594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 6778) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 9207968) |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2020-09-18 |