| NPI | 1417645193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NE 115307) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 10455165-4405) |
| Enumeration Date | 2023-05-01 |
| Last Update Date | 2024-05-30 |