| NPI | 1164710539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1737) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R2034566) |
| Enumeration Date | 2011-07-19 |
| Last Update Date | 2020-08-10 |