| NPI | 1891451365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VT 101.0137193) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN 10023) |
| Enumeration Date | 2021-11-09 |
| Last Update Date | 2024-11-12 |