| NPI | 1649481698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN R 228559-3) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA 057335) |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2017-11-29 |