| NPI | 1568019867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11022603) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-08-21 |
| Last Update Date | 2022-10-23 |