| NPI | 1831653302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VT 101.0139266) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WI 244422-30) |
| Enumeration Date | 2019-01-29 |
| Last Update Date | 2026-07-12 |