| NPI | 1093788655 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051826) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT001481A) |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2016-07-21 |