| NPI | 1710969159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 146028) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 146028) |
| 363L00000X Nurse Practitioner (Licence: IL 041238461) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2011-02-07 |