| NPI | 1619401718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IL 085.009495) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MI 6801098845) |
| Enumeration Date | 2017-04-14 |
| Last Update Date | 2023-01-30 |