| NPI | 1417410226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN80) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 363A00000X Physician Assistant (Licence: PR 1597) | |
| 363A00000X Physician Assistant (Licence: FL TPPA535) | |
| 363A00000X Physician Assistant (Licence: AZ 10352) | |
| 163W00000X Registered Nurse (Licence: FL RN9629527) | |
| Enumeration Date | 2019-04-09 |
| Last Update Date | 2026-02-19 |