| NPI | 1205866878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT000821) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2009-04-14 |