| NPI | 1912743279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704360497) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH APRN.CNP.0039368) |
| Enumeration Date | 2024-07-06 |
| Last Update Date | 2025-10-12 |