| NPI | 1639897994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R242127) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MD R242127) |
| 163W00000X Registered Nurse (Licence: PA RN728040) | |
| Enumeration Date | 2022-08-22 |
| Last Update Date | 2023-04-11 |