| NPI | 1104719137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11039812) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11039812) |
| 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11039812) | |
| 363LF0000X Nurse Practitioner, Family (Licence: FL 11039812) | |
| Enumeration Date | 2025-05-29 |
| Last Update Date | 2025-08-06 |