| NPI | 1932693991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL PA9113229) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113229) |
| Enumeration Date | 2018-06-21 |
| Last Update Date | 2024-10-29 |