| NPI | 1285830844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1411) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R 134445-1) |
| Enumeration Date | 2007-06-21 |
| Last Update Date | 2020-08-07 |