| NPI | 1962260406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5021032) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 172859) |
| Enumeration Date | 2024-03-11 |
| Last Update Date | 2025-04-02 |