| NPI | 1659229102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10042242) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024196971) |
| Enumeration Date | 2026-03-19 |
| Last Update Date | 2026-08-17 |