| NPI | 1679203244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95025925) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95258133) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95025925) | |
| Enumeration Date | 2022-06-15 |
| Last Update Date | 2023-10-20 |