| NPI | 1275043077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 404654) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN168720) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: NY F308186) | |
| Enumeration Date | 2017-10-05 |
| Last Update Date | 2025-07-28 |