| NPI | 1114695178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209024092) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209024092) |
| 163W00000X Registered Nurse (Licence: IL 041.460911) | |
| Enumeration Date | 2021-09-02 |
| Last Update Date | 2023-12-16 |