| NPI | 1720624471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11015353) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9471464) |
| Enumeration Date | 2019-11-18 |
| Last Update Date | 2023-05-31 |