| NPI | 1154692697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IA G178633) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KS 14-153435-051) |
| Enumeration Date | 2012-01-14 |
| Last Update Date | 2026-08-12 |