| NPI | 1356123657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 77813) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: ID TEMP77813) |
| Enumeration Date | 2023-10-20 |
| Last Update Date | 2025-06-23 |