| NPI | 1710472493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 5979) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 8582) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2020-10-27 |