| NPI | 1457692519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN CNP2339) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R-162384-2) |
| Enumeration Date | 2013-03-13 |
| Last Update Date | 2018-12-11 |