| NPI | 1760432058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9101790) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: FL PY0006467) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2023-01-20 |