| NPI | 1013436062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA19080) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 13744) |
| 101YP2500X Counselor, Professional (Licence: MS 2281) | |
| 101YP2500X Counselor, Professional (Licence: TX 75012) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA19080) | |
| Enumeration Date | 2017-09-11 |
| Last Update Date | 2025-04-30 |