| NPI | 1104423573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1015717) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 875228) |
| Enumeration Date | 2020-10-07 |
| Last Update Date | 2023-11-25 |