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 |