| NPI | 1760059695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WA 61188267) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 403512) |
| Enumeration Date | 2021-06-09 |
| Last Update Date | 2022-08-23 |