| NPI | 1275523193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MN R165377-3) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 900422) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN R165377-3) | |
| Enumeration Date | 2005-10-22 |
| Last Update Date | 2015-07-09 |