| NPI | 1043654635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 403269) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 681940) |
| 164W00000X Licensed Practical Nurse (Licence: NY 313860) | |
| Enumeration Date | 2013-04-25 |
| Last Update Date | 2020-10-21 |