| NPI | 1194267575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 127680) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 077999) |
| Enumeration Date | 2016-11-16 |
| Last Update Date | 2024-08-19 |