| NPI | 1457782336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 3076) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1280845) |
| Enumeration Date | 2013-12-03 |
| Last Update Date | 2020-10-06 |