| NPI | 1568601623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5019872) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: NY 287660) |
| Enumeration Date | 2009-02-13 |
| Last Update Date | 2024-05-18 |