| NPI | 1912888041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2025042945) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MO 2015029737) |
| Enumeration Date | 2025-09-08 |
| Last Update Date | 2025-10-16 |