NPI | 1154859874 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant |
Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36002774A) |
Enumeration Date | 2017-05-25 |
Last Update Date | 2025-06-05 |