| NPI | 1417550948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 12522) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R-2299916) |
| Enumeration Date | 2020-11-18 |
| Last Update Date | 2025-08-16 |