| NPI | 1689417529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN 11739) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 2377155) |
| Enumeration Date | 2024-06-18 |
| Last Update Date | 2026-08-04 |