| NPI | 1346929312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95025993) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-07-17 |
| Last Update Date | 2025-10-06 |