| NPI | 1275748089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-952) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-492) |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2025-08-03 |