| NPI | 1336102763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN R0820659) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP2295) |
| Enumeration Date | 2006-04-07 |
| Last Update Date | 2013-12-30 |