| NPI | 1396810529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 11054) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: TN 11054) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: VA 0024166489) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024166489) | |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2015-04-28 |