| NPI | 1093335697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003295) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-04-23 |
| Last Update Date | 2024-07-05 |