| NPI | 1689139669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NE 112752) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA G153862) |
| Enumeration Date | 2019-02-05 |
| Last Update Date | 2026-03-20 |