| NPI | 1326452251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111571) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9111571) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL3823) | |
| Enumeration Date | 2014-06-18 |
| Last Update Date | 2021-02-15 |