| NPI | 1407478936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024179594) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0001265634) |
| Enumeration Date | 2020-05-06 |
| Last Update Date | 2021-07-21 |