| NPI | 1225534977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 5765) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 9231) |
| 363L00000X Nurse Practitioner (Licence: WI 247144-30) | |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2020-12-18 |