| NPI | 1679458475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KS 53-84615-031) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 895965) |
| Enumeration Date | 2025-08-11 |
| Last Update Date | 2025-09-07 |