| NPI | 1336780014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: NY 758196) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 403148) |
| Enumeration Date | 2019-10-03 |
| Last Update Date | 2020-09-01 |