| NPI | 1417189135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WI 151309) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 151309) |
| Enumeration Date | 2009-08-13 |
| Last Update Date | 2017-04-12 |