| NPI | 1336709187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AL PA.2375) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 2529) |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2025-04-03 |