| NPI | 1780924092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1554) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1832947) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: SD CP000776) | |
| Enumeration Date | 2013-02-22 |
| Last Update Date | 2020-10-05 |