| NPI | 1528093077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ND R27650) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1561072) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2012-05-23 |