| NPI | 1770912305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 95000053) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R-165472-7) |
| Enumeration Date | 2013-11-04 |
| Last Update Date | 2017-03-01 |