| NPI | 1164069977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1029379) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: TX 818130) |
| Enumeration Date | 2019-11-30 |
| Last Update Date | 2021-03-29 |