| NPI | 1619795143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 2305) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: FL RBT-24-392034) |
| Enumeration Date | 2024-10-02 |
| Last Update Date | 2024-11-25 |