| 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 |