| NPI | 1700613189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 407199) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 587888) |
| Enumeration Date | 2024-09-18 |
| Last Update Date | 2025-09-29 |