| NPI | 1861945743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN CNP4747) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MN R190864-8) |
| Enumeration Date | 2016-07-27 |
| Last Update Date | 2020-10-29 |