| NPI | 1134683394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 2709) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2019-01-22 |
| Last Update Date | 2023-05-05 |