| NPI | 1083107056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3012754) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3012754) |
| Enumeration Date | 2018-06-13 |
| Last Update Date | 2023-03-28 |