| NPI | 1790563914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD AC005887) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024188119) |
| Enumeration Date | 2023-09-19 |
| Last Update Date | 2024-06-24 |