| NPI | 1760846042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 6518) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CT 12.006518) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CT 12.006518) | |
| Enumeration Date | 2016-04-12 |
| Last Update Date | 2025-08-15 |