| NPI | 1376096693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 4720) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN 1376096693) |
| Enumeration Date | 2016-08-03 |
| Last Update Date | 2020-08-10 |