| NPI | 1346732658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CA 55713) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2021-12-30 |