| NPI | 1053983098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5016227) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024182168) |
| 163W00000X Registered Nurse (Licence: NC 284170) | |
| Enumeration Date | 2021-07-10 |
| Last Update Date | 2024-01-02 |