| NPI | 1720102312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3005507) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209006516) |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2016-05-12 |