| NPI | 1699159822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10121208-1206) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: UT 10121208-1206) |
| Enumeration Date | 2015-07-17 |
| Last Update Date | 2026-01-05 |