| NPI | 1174041867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13930) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-09-01 |
| Last Update Date | 2024-03-07 |