| NPI | 1154896868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10017850) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ AP11821) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2025-07-25 |