| NPI | 1104400837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2023035006) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2021016520) |
| Enumeration Date | 2021-05-10 |
| Last Update Date | 2024-01-13 |