| NPI | 1649352139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-855) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: ID PA-855) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2023-11-27 |