| NPI | 1356607170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 3036-A) |
| 101YM0800X Counselor, Mental Health (Licence: NC A9545) | |
| Enumeration Date | 2012-04-05 |
| Last Update Date | 2019-07-11 |