| NPI | 1770336703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY 407406) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 750620) |
| Enumeration Date | 2024-04-09 |
| Last Update Date | 2026-04-24 |