| NPI | 1124605571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11014564) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2021-03-24 |
| Last Update Date | 2021-09-29 |