| NPI | 1922510007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MN 5458) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN 2041452) |
| Enumeration Date | 2017-10-30 |
| Last Update Date | 2017-10-30 |