| NPI | 1619596772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5015132) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AL 1-173916) |
| Enumeration Date | 2020-04-09 |
| Last Update Date | 2022-05-25 |