| NPI | 1508417957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: AZ 7636) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7636) |
| Enumeration Date | 2019-09-26 |
| Last Update Date | 2025-08-12 |