| 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 |