| NPI | 1609243906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 10983) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 6543) |
| Enumeration Date | 2015-08-21 |
| Last Update Date | 2024-01-03 |