| NPI | 1083625461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110001960) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health (Licence: VA 0110001960) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2025-10-07 |