| NPI | 1104547173 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 9210) | 
| Additional Taxonomies | 101YM0800X Counselor, Mental Health | 
| 363A00000X Physician Assistant (Licence: IL 085.009077) | |
| 363A00000X Physician Assistant (Licence: AZ 9210) | |
| Enumeration Date | 2022-09-08 | 
| Last Update Date | 2025-08-22 |