| NPI | 1639607757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IA A148861) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2009015609) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MN 10835) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IA G163179) | |
| Enumeration Date | 2017-06-02 |
| Last Update Date | 2025-10-28 |