| NPI | 1992255400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: MN 4759) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MN R193119-4) |
| Enumeration Date | 2016-10-07 |
| Last Update Date | 2021-03-02 |