| NPI | 1265665178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AL PA.1896) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 994) |
| Enumeration Date | 2009-08-25 |
| Last Update Date | 2022-01-27 |