| NPI | 1417207051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024174031) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 803743) |
| Enumeration Date | 2012-09-11 |
| Last Update Date | 2016-10-27 |