| NPI | 1194188490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10498) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001457) |
| Enumeration Date | 2016-04-04 |
| Last Update Date | 2021-08-02 |