| NPI | 1215349410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NH 1506) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NH 0404) |
| Enumeration Date | 2014-05-22 |
| Last Update Date | 2019-09-05 |