| NPI | 1306724505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 4012097) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 4012097) |
| Enumeration Date | 2025-08-25 |
| Last Update Date | 2026-02-11 |