| NPI | 1831073667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MN 13153) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN 13153) |
| Enumeration Date | 2025-08-04 |
| Last Update Date | 2025-08-04 |