| NPI | 1750124111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209029542) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.029542) |
| Enumeration Date | 2024-06-14 |
| Last Update Date | 2024-06-26 |