| NPI | 1124781836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11015066) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11015066) |
| Enumeration Date | 2021-10-19 |
| Last Update Date | 2026-01-05 |