| NPI | 1033570833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN 6365) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 5370160302) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-03-08 |
| Last Update Date | 2025-03-03 |