| NPI | 1154732360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2326) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R 168856-0) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN CNP2326) | |
| Enumeration Date | 2014-05-12 |
| Last Update Date | 2021-08-27 |