| NPI | 1346673274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15597) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MI 6801095650) |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2025-08-05 |