| NPI | 1700351384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11042100) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator (Licence: FL CBHCM101972-P) |
| Enumeration Date | 2018-10-10 |
| Last Update Date | 2025-09-14 |