| NPI | 1336699255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 277001999) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.018327) |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: PA SP016547) | |
| Enumeration Date | 2016-10-04 |
| Last Update Date | 2025-11-26 |