| NPI | 1679084024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: LA 215873) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MS 902297) |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2026-07-27 |