| NPI | 1407465693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95017415) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 305284) |
| Enumeration Date | 2020-07-23 |
| Last Update Date | 2026-04-15 |