| NPI | 1811717200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 12172) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN 12172) |
| Enumeration Date | 2024-10-11 |
| Last Update Date | 2025-01-08 |