| NPI | 1215196134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OR PA161231) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2008-06-05 |
| Last Update Date | 2013-08-19 |