| NPI | 1316591324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL PA9112319) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9112319) |
| Enumeration Date | 2019-07-29 |
| Last Update Date | 2022-05-03 |