| NPI | 1003254228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL3527) |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2019-09-19 |