| NPI | 1174685986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MA RN252000) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CT 003515) |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2022-01-14 |