| NPI | 1194908046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 8539) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL2392) |
| 363A00000X Physician Assistant (Licence: IN 10001376A) | |
| 363A00000X Physician Assistant (Licence: KY TC362) | |
| Enumeration Date | 2007-12-14 |
| Last Update Date | 2017-10-13 |