| NPI | 1073174538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 8836) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MT NUR-APRN-LIC-145495) |
| Enumeration Date | 2019-06-25 |
| Last Update Date | 2021-12-28 |