| NPI | 1740902766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 51721) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NM 54721) |
| 251S00000X (Licence: AZ 288707) | |
| Enumeration Date | 2022-09-15 |
| Last Update Date | 2023-08-21 |