| NPI | 1982393716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95028099) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95088490) |
| Enumeration Date | 2023-05-08 |
| Last Update Date | 2025-09-15 |