| NPI | 1174006563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 6246) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN 2018020875) |
| Enumeration Date | 2018-09-11 |
| Last Update Date | 2022-02-18 |