NPI | 1164931960 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.011631) |
Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 003657-1) | |
Enumeration Date | 2017-09-25 |
Last Update Date | 2025-09-17 |