| NPI | 1578136065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: MI 4704411604) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AZ 257653) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2025-07-08 |