| NPI | 1134424641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: UT 6833666-1206) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: UT 68336662501) |
| Enumeration Date | 2011-01-13 |
| Last Update Date | 2023-11-24 |