| NPI | 1972960706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: NC 001006163) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06163) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-06163) | |
| Enumeration Date | 2016-01-25 |
| Last Update Date | 2022-09-05 |