| NPI | 1679915706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MN 5139) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R-190688-6) |
| 163W00000X Registered Nurse (Licence: NY 657718) | |
| 363LF0000X Nurse Practitioner Family (Licence: NY F338490-1) | |
| Enumeration Date | 2013-07-17 |
| Last Update Date | 2021-12-16 |