| NPI | 1811121551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024178243) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 2008010430) |
| 286500000X Military Hospital | |
| Enumeration Date | 2009-05-11 |
| Last Update Date | 2023-04-04 |