| NPI | 1376917385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD 174442) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: MD R174442) |
| Enumeration Date | 2015-11-15 |
| Last Update Date | 2020-01-13 |