| NPI | 1093076929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 804) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1490130) |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2021-10-29 |