| NPI | 1063104602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11026190) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209026902) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL Pending) | |
| Enumeration Date | 2023-05-23 |
| Last Update Date | 2024-03-29 |