| NPI | 1275162612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9113109) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: FL PA9113109) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2022-03-15 |