| NPI | 1750751137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11007600) |
| Additional Taxonomies | 261Q00000X Clinic/Center |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11007600) | |
| Enumeration Date | 2015-09-29 |
| Last Update Date | 2021-12-13 |