| NPI | 1528031598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1760) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R077125-8) |
| Enumeration Date | 2006-02-09 |
| Last Update Date | 2020-08-10 |