| NPI | 1194215830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN 2033172) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R2033172) |
| 363LF0000X Nurse Practitioner, Family (Licence: ND 41156) | |
| Enumeration Date | 2018-05-17 |
| Last Update Date | 2022-04-29 |