| NPI | 1619329133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MN CNP 4615) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 4615) |
| Enumeration Date | 2016-07-08 |
| Last Update Date | 2021-10-09 |