| NPI | 1316679822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA64553) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| 363A00000X Physician Assistant (Licence: NC 0010-13933) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-06-24 |
| Last Update Date | 2024-10-04 |