| NPI | 1336593292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 82405) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3011769) |
| Enumeration Date | 2016-04-18 |
| Last Update Date | 2018-12-12 |