| NPI | 1790137354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 8591) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN 8591) |
| 363LF0000X Nurse Practitioner, Family (Licence: WI 7045-33) | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2025-07-11 |