| NPI | 1770469009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: NY 787159) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY pending) |
| Enumeration Date | 2025-08-13 |
| Last Update Date | 2025-09-11 |