NPI | 1417459876 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NJ 25MP00459100) |
Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: NJ 25MP00459100) |
363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00459100) | |
363AM0700X Physician Assistant, Medical (Licence: NY 0211611) | |
363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 021611) | |
Enumeration Date | 2018-03-01 |
Last Update Date | 2024-01-05 |