| NPI | 1083004576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10410) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002646) |
| Enumeration Date | 2015-02-04 |
| Last Update Date | 2024-03-11 |