| NPI | 1225712748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 34069) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5022877) |
| Enumeration Date | 2023-06-14 |
| Last Update Date | 2025-12-04 |