| NPI | 1366077885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 11588) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 9934) |
| Enumeration Date | 2020-03-04 |
| Last Update Date | 2025-07-31 |