| NPI | 1245669688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2539) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R170173-5) |
| Enumeration Date | 2013-11-06 |
| Last Update Date | 2020-08-07 |