| NPI | 1992799506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WI 142395) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN R153869-4) |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2011-02-15 |