| NPI | 1194480335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NY 348517) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 407104) |
| Enumeration Date | 2021-11-02 |
| Last Update Date | 2025-07-01 |