| NPI | 1275815680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ND R36899) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R230646-9) |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2015-12-04 |