| NPI | 1962115675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11023707) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11023707) |
| Enumeration Date | 2022-12-28 |
| Last Update Date | 2025-07-29 |