| NPI | 1154352789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 103712) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 103712) | |
| 363A00000X Physician Assistant (Licence: MD C0003059) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA053489) | |
| 363A00000X Physician Assistant (Licence: PA MA053489) | |
| 363A00000X Physician Assistant (Licence: NC 103712) | |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA053489) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 103712) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2024-01-05 |