| NPI | 1245758317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008341) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MI 5601008341) |
| Enumeration Date | 2017-09-08 |
| Last Update Date | 2019-09-27 |