| NPI | 1003461401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: ID PA-1924) | |
| Enumeration Date | 2019-08-03 |
| Last Update Date | 2024-08-21 |