| NPI | 1295592376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: FL 1777) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 24674) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95029252) | |
| 261QP2300X Clinic/Center, Primary Care (Licence: PR 24674) | |
| Enumeration Date | 2024-03-05 |
| Last Update Date | 2026-01-08 |