| NPI | 1659156032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024190492) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WI 14281-33) |
| Enumeration Date | 2023-08-25 |
| Last Update Date | 2024-08-06 |