| NPI | 1164688156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 200850087NP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OR 200850087NP) |
| Enumeration Date | 2008-07-30 |
| Last Update Date | 2013-08-20 |