| NPI | 1962779991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 267) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R175181-1) |
| Enumeration Date | 2011-11-18 |
| Last Update Date | 2021-08-17 |