| NPI | 1174779177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 006030) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WA RC60035704) |
| Enumeration Date | 2008-08-11 |
| Last Update Date | 2011-05-18 |