| NPI | 1194360404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2019-11-11 |
| Last Update Date | 2024-12-05 |