| NPI | 1356864300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11015094) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL F04210204) |
| 247200000X Technician, Other | |
| Enumeration Date | 2017-07-21 |
| Last Update Date | 2026-02-11 |