| NPI | 1679252027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: LA 206593) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11027857) |
| Enumeration Date | 2023-07-13 |
| Last Update Date | 2024-09-06 |