| NPI | 1275752297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SD 0979) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SD 0223) |
| 363AS0400X Physician Assistant, Surgical (Licence: IA 081265) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NE 2289) | |
| Enumeration Date | 2007-04-25 |
| Last Update Date | 2020-05-21 |