| NPI | 1073074431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: VA 0110006781) |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110006781) | |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2021-04-13 |