| NPI | 1609412410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.023658) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041.433033) |
| Enumeration Date | 2019-11-27 |
| Last Update Date | 2022-03-25 |