| NPI | 1265164784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95021352) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95021352) |
| Enumeration Date | 2022-06-24 |
| Last Update Date | 2022-10-11 |