| NPI | 1982850780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 2382) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN R165582-3) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R 165582-3) | |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2020-08-10 |