| NPI | 1093249419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 7588) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R-161518-0) |
| Enumeration Date | 2017-04-12 |
| Last Update Date | 2026-06-19 |