| NPI | 1114329810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8177613-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT 8177613-4810) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2014-09-24 |
| Last Update Date | 2021-09-08 |