| NPI | 1700158375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO 0101294) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CO 0991428) |
| Enumeration Date | 2012-01-29 |
| Last Update Date | 2022-02-01 |