| NPI | 1811500226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ND R29139) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN 12993) |
| Enumeration Date | 2020-08-25 |
| Last Update Date | 2026-03-30 |