| NPI | 1073872354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: WY 23848.1193) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WY 23848) |
| Enumeration Date | 2012-05-08 |
| Last Update Date | 2012-10-02 |