| NPI | 1770192742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH 0028527) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024179781) |
| Enumeration Date | 2020-07-27 |
| Last Update Date | 2021-05-21 |