| NPI | 1780934885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6903) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 6903) |
| 183500000X Pharmacist (Licence: AZ s016660) | |
| Enumeration Date | 2012-09-15 |
| Last Update Date | 2026-07-02 |