| NPI | 1164990719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD 236376) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: DC RN1048979) |
| Enumeration Date | 2018-11-12 |
| Last Update Date | 2023-12-08 |