| NPI | 1104535749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: PA SP030531) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: DE L8-0010367) |
| Enumeration Date | 2022-11-22 |
| Last Update Date | 2026-02-24 |