| NPI | 1982208716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2025009025) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2020-11-23 |
| Last Update Date | 2026-01-28 |