| NPI | 1194103754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 3919) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1902576) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2020-08-10 |