| NPI | 1255957759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 10639) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 218012-2) |
| 363LA2100X Nurse Practitioner, Acute Care (Licence: MN 7564) | |
| Enumeration Date | 2020-06-19 |
| Last Update Date | 2021-01-13 |