| NPI | 1720688005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11029474) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3015035) |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2024-07-10 |