| NPI | 1518504307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R208967) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MD 2019051520) |
| Enumeration Date | 2019-11-29 |
| Last Update Date | 2022-03-29 |