| NPI | 1174800072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: GA RN214076) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN214076) |
| 363LF0000X Nurse Practitioner, Family (Licence: SC 17634) | |
| Enumeration Date | 2011-11-07 |
| Last Update Date | 2022-01-21 |