| NPI | 1912500802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1027095) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NM 61943) |
| Enumeration Date | 2020-11-21 |
| Last Update Date | 2021-03-25 |