| NPI | 1902462039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 58483) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 202201741NP-PP) |
| Enumeration Date | 2019-05-14 |
| Last Update Date | 2024-06-06 |