| NPI | 1659770519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: PA SP014107) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: PA SP014107) |
| Enumeration Date | 2014-08-17 |
| Last Update Date | 2025-02-14 |