| NPI | 1194042663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN CNP104) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: MN R171736-3) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R-171736-3) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R171736-3) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WI 11074-33) | |
| Enumeration Date | 2010-04-23 |
| Last Update Date | 2024-05-15 |