| NPI | 1790134948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3010331) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3010331) |
| Enumeration Date | 2016-06-08 |
| Last Update Date | 2021-11-02 |