| NPI | 1104387752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 223931) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3015271) |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2022-10-24 |