| NPI | 1891336111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WV 104731) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 104731) |
| Enumeration Date | 2019-10-08 |
| Last Update Date | 2024-09-05 |