| NPI | 1205195385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 585) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R206814-7) |
| 363L00000X Nurse Practitioner (Licence: MN R2068147) | |
| 363L00000X Nurse Practitioner (Licence: WI 23436) | |
| 363LF0000X Nurse Practitioner, Family (Licence: IA 114081) | |
| Enumeration Date | 2012-05-10 |
| Last Update Date | 2023-01-27 |