| NPI | 1104709229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024194363) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001248797) |
| Enumeration Date | 2025-07-28 |
| Last Update Date | 2025-08-21 |