| NPI | 1336021138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 13137) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10020104) |
| Enumeration Date | 2025-07-23 |
| Last Update Date | 2025-07-24 |