| NPI | 1083222558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 27202) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: TN 27202) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 0024184676) | |
| Enumeration Date | 2020-07-21 |
| Last Update Date | 2024-01-26 |