| NPI | 1407419419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2472321) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IA A145482) |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2020-05-10 |