| NPI | 1245608553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2015030561) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MO 2015030561) |
| 363L00000X Nurse Practitioner (Licence: MO 2015030561) | |
| Enumeration Date | 2015-09-03 |
| Last Update Date | 2025-03-04 |