| NPI | 1124494414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN 4761) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN CNP 4761) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 4761) | |
| Enumeration Date | 2015-08-20 |
| Last Update Date | 2021-09-27 |