| NPI | 1790065738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 75884) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: KY 3009120) |
| Enumeration Date | 2011-08-22 |
| Last Update Date | 2026-02-04 |