| NPI | 1083166391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15075) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: NC 6022) |
| Enumeration Date | 2016-11-03 |
| Last Update Date | 2025-07-16 |