| NPI | 1245705235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MT MED-APRN-LIC-158319) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO APN.0994176) |
| Enumeration Date | 2018-10-05 |
| Last Update Date | 2023-08-17 |