| NPI | 1629960018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MN 13177) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 2485839) |
| Enumeration Date | 2025-07-18 |
| Last Update Date | 2025-08-07 |