| NPI | 1275855231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 5473) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AZ 0090) |
| Enumeration Date | 2010-02-18 |
| Last Update Date | 2014-06-03 |