| NPI | 1700330008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3010286) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3010286) |
| Enumeration Date | 2016-08-04 |
| Last Update Date | 2021-07-22 |