| NPI | 1043666530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 5830) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IA 123314) |
| 163WC0200X Registered Nurse Critical Care Medicine (Licence: MN 1919239) | |
| 363LP0200X Nurse Practitioner Pediatrics (Licence: WI 7140) | |
| 363LP0200X Nurse Practitioner Pediatrics (Licence: MN 5830) | |
| Enumeration Date | 2016-05-13 |
| Last Update Date | 2023-12-13 |