| NPI | 1265112312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 10632) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 14497) |
| Enumeration Date | 2023-07-24 |
| Last Update Date | 2023-09-12 |