| NPI | 1700555398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 30325) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO 104514) |
| Enumeration Date | 2021-09-08 |
| Last Update Date | 2025-10-01 |