| NPI | 1124330196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN CNP4094) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL ARNP 9175894) |
| 363LF0000X Nurse Practitioner, Family (Licence: NY 339947) | |
| Enumeration Date | 2010-07-07 |
| Last Update Date | 2016-01-09 |