| NPI | 1669741336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN R2068529) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO 183387) |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2012-10-09 |