| NPI | 1710616032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5017946) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5017946) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 200349) | |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2023-04-14 |