| NPI | 1689381691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: TN 99476) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TN 99476) |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: TN 99476) | |
| Enumeration Date | 2022-10-31 |
| Last Update Date | 2022-10-31 |