| NPI | 1689987794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1092) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: ID LPC1092) |
| 101YP2500X Counselor, Professional (Licence: ID LPC-4266) | |
| Enumeration Date | 2010-07-18 |
| Last Update Date | 2025-03-04 |