| NPI | 1669145736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 106S00000X Behavior Technician |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2021-07-26 |
| Last Update Date | 2025-08-15 |