| NPI | 1861061673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 10684) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 978412) |
| 363LF0000X Nurse Practitioner, Family (Licence: TX 1094524) | |
| Enumeration Date | 2021-06-24 |
| Last Update Date | 2024-10-15 |