| NPI | 1104352269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R155630) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: PA RN526107L) |
| 163WP0808X Registered Nurse, Psych/Mental Health (Licence: PA RN526107L) | |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2023-11-08 |