| NPI | 1356468052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003521) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 126000086) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2020-10-20 |