| NPI | 1245413095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200007) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT4419) | |
| Enumeration Date | 2007-12-14 |
| Last Update Date | 2017-06-06 |