| NPI | 1033248042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA150016) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OR AT-AT-115483) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-03-05 |
| Last Update Date | 2021-05-18 |