| NPI | 1639711716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11012435) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9559520) |
| 163W00000X Registered Nurse (Licence: PA rn668868) | |
| 363L00000X Nurse Practitioner (Licence: PA SP021125) | |
| 363L00000X Nurse Practitioner (Licence: FL 11012435) | |
| Enumeration Date | 2019-10-10 |
| Last Update Date | 2022-10-07 |