| NPI | 1215782230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WY 52431) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NE 115908) |
| Enumeration Date | 2024-04-22 |
| Last Update Date | 2025-03-31 |