| NPI | 1457739179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 3981) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R210059-7) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2021-01-19 |