| NPI | 1053914564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1019825) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 1019825) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 100166290) | |
| Enumeration Date | 2020-11-17 |
| Last Update Date | 2023-10-27 |