| NPI | 1639698244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209020355) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-77844-122) |
| 363LF0000X Nurse Practitioner, Family (Licence: IL 209020355) | |
| Enumeration Date | 2017-09-14 |
| Last Update Date | 2020-07-21 |