| NPI | 1720735731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95019147) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95019147) |
| Enumeration Date | 2022-03-09 |
| Last Update Date | 2024-12-10 |