| NPI | 1063184968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 74368) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WY 40375) |
| Enumeration Date | 2021-09-29 |
| Last Update Date | 2022-10-31 |