| NPI | 1508106873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA RN758858) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5021994) |
| Enumeration Date | 2013-02-25 |
| Last Update Date | 2025-09-12 |