| NPI | 1104669415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 11846) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN F05240660) |
| Enumeration Date | 2024-06-14 |
| Last Update Date | 2024-09-25 |