| NPI | 1891345369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 7096) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11001823) |
| Enumeration Date | 2019-09-17 |
| Last Update Date | 2020-09-18 |