| NPI | 1013514421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 58169) |
| Additional Taxonomies | 2084A0401X Psychiatry & Neurology, Addiction Medicine (Licence: AZ 250776) |
| Enumeration Date | 2020-10-08 |
| Last Update Date | 2023-06-21 |