| NPI | 1376128447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VT 055.0031537) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031537) |
| Enumeration Date | 2021-03-10 |
| Last Update Date | 2023-03-29 |