| NPI | 1760783963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 21279) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI PA21279) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 21279) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 21279) | |
| Enumeration Date | 2010-11-04 |
| Last Update Date | 2024-03-06 |