| NPI | 1013453927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10004771A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36002817A) |
| Enumeration Date | 2017-01-17 |
| Last Update Date | 2025-03-10 |