| NPI | 1619512415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 403624) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 781695) |
| Enumeration Date | 2019-11-15 |
| Last Update Date | 2021-09-14 |