| NPI | 1073061537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 4660) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MN CNP 4660) |
| Enumeration Date | 2016-09-13 |
| Last Update Date | 2022-02-04 |