| NPI | 1760853600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CO 0991980) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CO 0991980) |
| Enumeration Date | 2015-10-19 |
| Last Update Date | 2025-03-29 |