| NPI | 1063995629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 6100) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 8758) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN 1854912) | |
| Enumeration Date | 2018-09-10 |
| Last Update Date | 2024-04-04 |