NPI | 1013960368 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01366) |
Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 791039) |
363A00000X Physician Assistant | |
Enumeration Date | 2006-05-18 |
Last Update Date | 2020-11-10 |