| NPI | 1962735753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN R 194672-3) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2261823) |
| Enumeration Date | 2009-09-10 |
| Last Update Date | 2010-08-17 |