| NPI | 1760851661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 4173) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN CNP 4173) |
| Enumeration Date | 2015-09-21 |
| Last Update Date | 2019-05-02 |