| NPI | 1104024652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024167448) |
| Additional Taxonomies | 364SP0809X Clinical Nurse Specialist, Psych/Mental Health, Adult (Licence: VA 0015000847) |
| 163W00000X Registered Nurse (Licence: VA 0001138067) | |
| Enumeration Date | 2007-07-06 |
| Last Update Date | 2010-04-20 |