| NPI | 1083960256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN R-164573-6) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R 164573-6) |
| Enumeration Date | 2012-07-25 |
| Last Update Date | 2020-08-10 |