| NPI | 1104624774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: UT 10826752-3102) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 10826752-4405) |
| Enumeration Date | 2025-03-07 |
| Last Update Date | 2026-03-20 |