| NPI | 1215993407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2220) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SD CP000515) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R 137351-6) | |
| Enumeration Date | 2006-04-25 |
| Last Update Date | 2020-08-07 |