| NPI | 1295169290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN CNP 1957) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ND R32294) |
| Enumeration Date | 2013-08-26 |
| Last Update Date | 2018-04-19 |