| NPI | 1700121332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 5254477-4405) |
| Additional Taxonomies | 163WP0809X Registered Nurse, Psych/Mental Health, Adult (Licence: UT 5254477-3102) |
| Enumeration Date | 2012-12-08 |
| Last Update Date | 2026-07-07 |