| NPI | 1114572757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163WA0400X Registered Nurse, Addiction (Substance Use Disorder) (Licence: FL 11015129) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 000340-P.A.) |
| Enumeration Date | 2019-08-08 |
| Last Update Date | 2022-04-19 |