| NPI | 1164850087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1960) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R 115885-4) |
| Enumeration Date | 2013-10-31 |
| Last Update Date | 2020-08-07 |