| NPI | 1780300574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ 282261) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2022-10-13 |
| Last Update Date | 2026-05-01 |