| NPI | 1366187296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: MN 9141) |
| Enumeration Date | 2022-05-04 |
| Last Update Date | 2025-12-23 |