| NPI | 1629642368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5014421) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 5014421) |
| 363LF0000X Nurse Practitioner, Family (Licence: NC 5014421) | |
| Enumeration Date | 2021-05-17 |
| Last Update Date | 2022-10-06 |