| NPI | 1023501764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08082) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000017943) |
| Enumeration Date | 2018-06-07 |
| Last Update Date | 2022-02-09 |