| NPI | 1336665710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2023012679) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2017022254) |
| 363L00000X Nurse Practitioner (Licence: MO 2017022254) | |
| Enumeration Date | 2017-08-17 |
| Last Update Date | 2025-10-22 |