| NPI | 1225659246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 7921) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 27553) |
| 363LF0000X Nurse Practitioner, Family (Licence: TN 27553) | |
| Enumeration Date | 2020-04-30 |
| Last Update Date | 2020-11-25 |