| NPI | 1699039511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1162) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CO 184069) |
| 363L00000X Nurse Practitioner (Licence: MN R2126335) | |
| 363LF0000X Nurse Practitioner, Family (Licence: CO APN.0990431) | |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2020-08-07 |