| NPI | 1770564932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN R143562-9) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MN R 143562 9) |
| Enumeration Date | 2005-11-07 |
| Last Update Date | 2018-01-09 |