| NPI | 1043777642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 402795) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 391345) |
| Enumeration Date | 2019-03-01 |
| Last Update Date | 2020-03-11 |