| NPI | 1639541022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95003306) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95003306) |
| Enumeration Date | 2015-10-23 |
| Last Update Date | 2020-03-01 |