| NPI | 1578730024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: AK 0912) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: AK 0360) |
| Enumeration Date | 2008-05-14 |
| Last Update Date | 2023-01-25 |