| NPI | 1063969806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024173930) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD AC002500) |
| Enumeration Date | 2016-09-09 |
| Last Update Date | 2023-07-10 |