| NPI | 1164835211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2277612) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F401696) |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2021-07-06 |