| NPI | 1104928886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 1178) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WI 1178) |
| Enumeration Date | 2006-09-02 |
| Last Update Date | 2011-08-25 |