| NPI | 1083109227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-3048) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-06-29 |
| Last Update Date | 2024-06-10 |