| NPI | 1215402813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL RN9485164) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator (Licence: FL CBHCM101723) |
| Enumeration Date | 2018-10-10 |
| Last Update Date | 2018-10-10 |