| NPI | 1639605710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 10110) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 23464) |
| 163W00000X Registered Nurse (Licence: TN 217578) | |
| Enumeration Date | 2017-05-10 |
| Last Update Date | 2025-09-22 |