| NPI | 1225478100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024177365) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001243595) |
| Enumeration Date | 2013-06-25 |
| Last Update Date | 2019-03-01 |