| NPI | 1427453216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2678) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1705618) |
| Enumeration Date | 2014-10-23 |
| Last Update Date | 2020-11-05 |