| NPI | 1104805340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 642) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R 145566-7) |
| Enumeration Date | 2006-01-16 |
| Last Update Date | 2024-11-08 |