| NPI | 1164505863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004290) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: VA 0701002996) |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2021-05-20 |