| NPI | 1881830636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: WY 33183.1300) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WY 1300) |
| Enumeration Date | 2008-12-29 |
| Last Update Date | 2023-03-10 |