| NPI | 1013313253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2014-11-17 |
| Last Update Date | 2022-01-27 |