| NPI | 1225536592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN xxx) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 227183-7) |
| Enumeration Date | 2018-01-31 |
| Last Update Date | 2020-07-31 |