| NPI | 1598173387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1987) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1961711) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R-196-171-1) | |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2020-08-10 |