| NPI | 1609325638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-16168) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2016-10-03 |
| Last Update Date | 2026-04-10 |