| NPI | 1457876591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5014648) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 271994) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5014648) | |
| Enumeration Date | 2017-08-10 |
| Last Update Date | 2022-05-11 |