| NPI | 1639638323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 25567) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024177366) |
| Enumeration Date | 2019-03-13 |
| Last Update Date | 2024-03-01 |