| NPI | 1194334359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 8964) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CT 8964) |
| 363LF0000X Nurse Practitioner Family (Licence: CT 8964) | |
| 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: CT 8964) | |
| 363LP2300X Nurse Practitioner Primary Care (Licence: CT 8964) | |
| Enumeration Date | 2020-07-23 |
| Last Update Date | 2024-04-24 |