| NPI | 1174123483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ME CNP231199) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO 0995967) |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2025-06-11 |