| NPI | 1720653652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 8226) |
| Additional Taxonomies | 163WP0807X Registered Nurse, Psych/Mental Health, Child & Adolescent (Licence: MN 1961290) |
| 363L00000X Nurse Practitioner (Licence: MN 8226) | |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2021-06-15 |