| NPI | 1548716004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MA 1548716004) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2310529) |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2020-03-31 |