| NPI | 1356819007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: FL APRN11005478) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 000000000) |
| Enumeration Date | 2018-11-09 |
| Last Update Date | 2022-11-10 |