| NPI | 1174116198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11021804) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9414770) |
| Enumeration Date | 2021-02-19 |
| Last Update Date | 2022-10-04 |