| NPI | 1164896874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F404462-01) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 704778-1) |
| Enumeration Date | 2015-11-18 |
| Last Update Date | 2022-11-21 |