| NPI | 1205873718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2009004342) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2002029422) |
| Enumeration Date | 2006-06-01 |
| Last Update Date | 2015-02-06 |