| NPI | 1093104879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061397) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: SC 2845) | |
| 363AM0700X Physician Assistant, Medical (Licence: SC 2845) | |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 2845) | |
| Enumeration Date | 2015-01-15 |
| Last Update Date | 2020-07-10 |