| NPI | 1972774552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024166755) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NM 59180) |
| Enumeration Date | 2008-03-21 |
| Last Update Date | 2020-08-17 |