| NPI | 1023078011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA1568) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 625) |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2023-02-10 |