| NPI | 1811072168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA05003) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX PA05003) | |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2025-06-02 |