| NPI | 1063413250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN CNP1090) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R-143255-4) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2023-06-07 |