| NPI | 1215567714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 58629) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: ID 58629) |
| Enumeration Date | 2020-01-23 |
| Last Update Date | 2022-09-06 |