| NPI | 1053693010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 7130) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R 200800-0) |
| Enumeration Date | 2011-09-15 |
| Last Update Date | 2020-02-04 |