| NPI | 1184192890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024177111) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 25109) |
| Enumeration Date | 2018-11-12 |
| Last Update Date | 2022-01-13 |