| NPI | 1548754039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.022514) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209.017716) |
| Enumeration Date | 2018-06-18 |
| Last Update Date | 2026-05-11 |