| NPI | 1295259000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 2000017302) |
| Enumeration Date | 2017-08-02 |
| Last Update Date | 2025-06-20 |