| NPI | 1215915525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 60) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R 097949-0) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2023-02-10 |