| NPI | 1225541808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA2514) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: ID AT-569) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-11-06 |
| Last Update Date | 2021-12-03 |