| NPI | 1497147409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95005007) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN AG0814094) |
| Enumeration Date | 2015-02-27 |
| Last Update Date | 2022-07-21 |