| NPI | 1194121715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA218438) |
| Additional Taxonomies | 101Y00000X Counselor |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2014-11-10 |
| Last Update Date | 2024-07-10 |