| NPI | 1245471663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6278) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 1353) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 6278) | |
| Enumeration Date | 2009-03-14 |
| Last Update Date | 2018-08-02 |