| NPI | 1225447626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA7872) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2416) |
| 363A00000X Physician Assistant (Licence: NV PA1851) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: RI AT00339) | |
| Enumeration Date | 2014-08-11 |
| Last Update Date | 2025-11-10 |