| NPI | 1699253294 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: SC 21993) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IN 71010511A) | 
| 363LF0000X Nurse Practitioner, Family (Licence: SC 21993) | |
| Enumeration Date | 2018-08-06 | 
| Last Update Date | 2025-07-02 |