| NPI | 1235678954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN 6103) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 6103) |
| Enumeration Date | 2017-02-14 |
| Last Update Date | 2020-07-22 |