| NPI | 1164107819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11027074) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11027074) |
| Enumeration Date | 2023-06-20 |
| Last Update Date | 2024-09-11 |