| NPI | 1134647019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SD 1108) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: ID PA1797) |
| Enumeration Date | 2017-08-31 |
| Last Update Date | 2021-08-02 |