| NPI | 1104237684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH APRN.CNP.0029881) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: OH PN134199M-IV) |
| Enumeration Date | 2014-05-18 |
| Last Update Date | 2021-12-15 |