| NPI | 1679503965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX pa00642) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX PA00642) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2025-04-29 |