| NPI | 1235637125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 6381032-4405) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041375125) |
| 163W00000X Registered Nurse (Licence: UT 6381032-3102) | |
| 363L00000X Nurse Practitioner (Licence: IL 209.017270) | |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2018-11-18 |