| NPI | 1316948524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C03153) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT002217A) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA051996) | |
| 363A00000X Physician Assistant (Licence: NY 0097831) | |
| 363A00000X Physician Assistant (Licence: DE C5-0000676) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2016-01-15 |