| NPI | 1487460382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MN 12903) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 2496848) |
| Enumeration Date | 2024-12-05 |
| Last Update Date | 2025-07-25 |