| NPI | 1306458062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10896) |
| Additional Taxonomies | 235Z00000X Speech-Language Pathologist, (Licence: NC 10551) |
| Enumeration Date | 2020-08-23 |
| Last Update Date | 2026-05-16 |