| NPI | 1861754764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 1094) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R1685835) |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2020-10-05 |