| NPI | 1306209416 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 339126) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200406) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-04-05 |
| Last Update Date | 2023-10-25 |