| NPI | 1558890749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO 0996458-NP) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 95006268) |
| 207QA0000X Family Medicine, Adolescent Medicine (Licence: CA 95006268) | |
| 207QA0505X Family Medicine, Adult Medicine (Licence: CA 95006268) | |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: CA 95006268) | |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2022-07-21 |