| NPI | 1023508751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA213270) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2018-05-17 |
| Last Update Date | 2025-11-12 |