| NPI | 1972264018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 9047281-4405) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 9074281-4405) |
| Enumeration Date | 2021-12-30 |
| Last Update Date | 2024-07-10 |