| NPI | 1629821194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 11829) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 2461272) |
| Enumeration Date | 2024-04-08 |
| Last Update Date | 2024-12-06 |