| NPI | 1194904375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002654) |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110002654) | |
| Enumeration Date | 2007-10-24 |
| Last Update Date | 2024-04-15 |