| 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 |