| NPI | 1124660956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11040467) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-10-14 |
| Last Update Date | 2026-02-25 |