| NPI | 1003502782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 277004103) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: IL 277004103) |
| Enumeration Date | 2023-04-14 |
| Last Update Date | 2025-05-07 |