| NPI | 1174016695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 8618829-1206) |
| Additional Taxonomies | 101Y00000X Counselor |
| Enumeration Date | 2018-06-09 |
| Last Update Date | 2024-03-13 |