| NPI | 1740663798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 3965) |
| Additional Taxonomies | 163WP0807X Registered Nurse, Psych/Mental Health, Child & Adolescent (Licence: MN CNP3965) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2022-01-17 |