| NPI | 1063900603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209017467) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209017467) |
| Enumeration Date | 2018-04-30 |
| Last Update Date | 2020-04-07 |