| NPI | 1023081593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10001483A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH 002388) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2021-02-13 |