| NPI | 1003159070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11018626) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041400561) |
| 163W00000X Registered Nurse (Licence: FL 9548024) | |
| Enumeration Date | 2013-03-28 |
| Last Update Date | 2023-06-21 |