| NPI | 1700274974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95010338) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 19606) |
| 363LF0000X Nurse Practitioner, Family (Licence: MI 4704335557) | |
| 363LF0000X Nurse Practitioner, Family (Licence: CA 95010338) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 19606) | |
| Enumeration Date | 2014-12-22 |
| Last Update Date | 2024-09-04 |