| NPI | 1023591872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 11717) |
| Enumeration Date | 2018-09-07 |
| Last Update Date | 2023-07-25 |