| NPI | 1740825678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024178639) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3014045) |
| Enumeration Date | 2019-11-14 |
| Last Update Date | 2022-08-09 |