| NPI | 1891237871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2111) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID GPA-075) |
| 101Y00000X Counselor | |
| Enumeration Date | 2016-11-08 |
| Last Update Date | 2023-09-13 |