| NPI | 1770962698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00433) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2019-09-18 |