| NPI | 1083261390 |
|---|---|
| Professional Name | NA NA NA |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: TX AP142663) |
| Enumeration Date | 2019-08-21 |
| Last Update Date | 2019-08-21 |