| NPI | 1033519194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 869) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WV AT001230) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-08-26 |
| Last Update Date | 2023-11-07 |