| NPI | 1295424125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2023-05-05 |
| Last Update Date | 2024-11-05 |