| NPI | 1760063846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: MN 2020389) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 8139) |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2025-10-13 |