| NPI | 1104485184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10240) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ ATR-001423) |
| Enumeration Date | 2019-06-12 |
| Last Update Date | 2024-05-17 |