| NPI | 1184714495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 102589) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 102589) |
| Enumeration Date | 2006-10-15 |
| Last Update Date | 2024-07-15 |