| NPI | 1114639911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95026874) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95175469) |
| Enumeration Date | 2022-12-23 |
| Last Update Date | 2025-11-14 |