| NPI | 1114900131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2267) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 627) |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2020-01-09 |