NPI | 1316948524 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C03153) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 0097831) |
363A00000X Physician Assistant (Licence: DE C5-0000676) | |
2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT002217A) | |
363AM0700X Physician Assistant, Medical (Licence: PA MA051996) | |
Enumeration Date | 2005-08-10 |
Last Update Date | 2025-09-05 |